Post Employment Medical Questionnaire


A post employment medical questionnaire is a tool with help of which the employers keep a medical record of all of its employees. The questions contained in it are framed to gather essential details about the medical health of the employee to be accessed when required.

Sample Post Employment Medical Questionnaire

Name:

Date of birth:

Age:

Contact No.:

Answer the questions:

1. Kindly provide the name of the medical practitioner you visit for your medical exams and treatment. Also provide his/ her address and contact no.

____________________________________________________________

2. Have you ever been employed or have worked in an organization with similar working conditions?

a. Yes

b. No

__________________________________, if yes then give the details.

3. Has any doctor or you practitioner ever restricted your activates?

a. Yes

b. No.

If yes then please mention the restrictions, the medical reason for the restriction, whether they were permanent or temporary and present restrictions if any.

_____________________________________________________________

4. Please mention or provide a list of any medical illness (major), allergies, disabilities or impairment you presently have or have had in the past. (Also give specifications like the age, time period etc.)

_____________________________________________________________

5. Have you been denied employment or recruitment to any job before on health grounds? Give specifications.

_____________________________________________________________

6. Have you ever or do you suffer from any work related health issues? Specify.

______________________________________________________________

7. Do you have an eyesight problem that cannot be corrected by eye glasses or lenses? Specify.

______________________________________________________________

8. Do you have any hearing problems which cannot be corrected by any hearing aid? Specify.

_______________________________________________________________

9. Do you have any back, neck or shoulder problems which may be aggravated or relapsed due to extensive working hours?

_______________________________________________________________

10. Have you has any sort of breathing problems like short breath, bronchitis etc. in the period of last five to ten years? Specify.

_______________________________________________________________

11. Are you currently undergoing any sort of a medical/ health treatment? Give details.

_______________________________________________________________

 

Category: Employment Questionnaire

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